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The Basics.  More than 100 million Americans receive care that is financed through Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP)

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Presentation on theme: "The Basics.  More than 100 million Americans receive care that is financed through Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP)"— Presentation transcript:

1 The Basics

2  More than 100 million Americans receive care that is financed through Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP)  Focused on transforming the U.S. health care system through ◦ Better care that is seamless and coordinated ◦ Improved health of the population ◦ Reduced rates of growth in health care spending through improvement.

3  10 Regional Offices ◦ Audit State and Contractor Operations ◦ Coordinate Outreach Activities  Central site in Baltimore, MD ◦ Writes regulations and guidance ◦ Coordinates national strategies for program implementation ◦ Oversees “Centers” responsible for key policy and operational areas

4  Health insurance for three groups of people ◦ 65 and older ◦ Under 65 with certain disabilities ◦ Any age with End-Stage Renal Disease (ESRD)  Administration ◦ Centers for Medicare & Medicaid Services (CMS)  Enrollment ◦ Social Security Administration (SSA) for most ◦ Railroad Retirement Board (RRB) railroad retirees 05/05/2011 4Getting Started

5 Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage (like HMOs and PPOs) Part D Medicare Prescription Drug Coverage 05/05/2011 Getting Started5

6  Has Part A – Hospital Insurance ◦ Hospital ◦ Skilled Nursing Facility ◦ Home health care ◦ Hospice care  Has Part B – Medical Insurance ◦ Doctor’s visits ◦ Outpatient hospital services ◦ Clinical lab tests ◦ Preventive services 05/05/2011 6Getting Started

7  Automatic for those receiving – Social Security benefits – Railroad Retirement Board benefits  Initial Enrollment Period Package – Mailed 3 months before 25th month of disability benefits Age 65 05/05/2011 Getting Started7

8 Jane Doe  Keep it and accept Medicare Parts A and B  Return it to refuse Part B – Follow instructions on back of card Front Back 05/05/2011 8Getting Started

9  Enrollment is not automatic ◦ If you don’t get Social Security or RRB benefits ◦ For instance, you are still actively working  Enroll with Social Security ◦ Visit local office ◦ Call 1-800-772-1213 ◦ Online at  If retired from Railroad enroll with RRB ◦ Call your local RRB office or 1‑877‑772‑5772 05/05/2011 9Getting Started

10  You don’t have to be retired  Your initial enrollment period lasts 7 months ◦ Begins three months before your 65 th birthday ◦ Includes the month you turn 65 ◦ Ends three months after you turn 65  There are other times you may enroll ◦ But you may pay a penalty if you delay enrolling 05/05/2011 10Getting Started

11  Consider ◦ Get it automatically if getting Social Security/RRB ◦ Free for most people ◦ Can pay if work history is not sufficient  There may be a penalty if you delay ◦ If you/your spouse is actively working and covered by employer plan  Contact Social Security to sign up 05/05/2011 11Getting Started

12  Consider ◦ Automatic if getting Social Security/RRB benefits ◦ Most people pay a monthly premium  Usually deducted from SS/RRB benefits  Amount depends on income (see Attachment C) ◦ It may supplement employer coverage 05/05/2011 12Getting Started

13  Sometimes you must have Part B ◦ If you want to buy a Medigap policy ◦ If you want to join a Medicare Advantage Plan ◦ If you are eligible for TRICARE ◦ If your employer coverage requires you have it  Talk to your employer’s benefits administrator  With Veterans benefits it’s optional ◦ But you pay a penalty if you sign up late If you don’t sign up during your initial enrollment period 05/05/2011 Getting Started13

14  If you don’t have coverage from active employment ◦ Yours or your spouses ◦ Delaying Part B may mean  Higher premiums  Paying for your health care out-of-pocket  If you do have coverage through active employment ◦ You may want to delay Part B ◦ No penalty if you enroll while you have coverage or within 8 months of losing coverage 05/05/2011 14Getting Started

15  Policies sold by private companies  Fill the gaps in Original Medicare ◦ Deductibles, coinsurance, copayments  Standardized plans in all but three states ◦ Minnesota, Massachusetts, Wisconsin  All plans of same letter have same coverage ◦ Only costs are different 05/05/2011 15Getting Started

16  Consider ◦ Do you have Original Medicare?  Medigap doesn’t work with Medicare Advantage ◦ Do you have other coverage that supplements Medicare?  You might not need Medigap ◦ Can you afford Medicare deductibles and copayments? ◦ How much will the monthly Medigap premium cost? 05/05/2011 16Getting Started

17 05/05/2011 Getting Started17 Medigap Benefits Medigap Plans ABCDF*GK**L**MN Part A Coinsurance Up to 365 Days Part B Coinsurance Blood Hospice Care Coinsurance Skilled Nursing Coinsurance 50%75% Part A Deductible 50%75%50% Part B Deductible Part B Excess Charges Foreign Travel Emergency (Up to Plan Limits) *Plan F has a high-deductible option ** Plans K and L have out-of-pocket limits of $4,640 and $2,320 respectively

18  By phone or computer ◦ Call 1 800 MEDICARE ◦ Visit and use the compare tool ◦ Call your SHIP ◦ The process  Choose standardized plan, like a Plan C, for example  Compare costs of all Plan C policies  The coverage is the same – the costs may be different 05/05/2011 18Getting Started

19  Health plan options approved by Medicare  Run by private companies  Medicare pays amount for each member’s care  Another way to get Medicare coverage  Part of the Medicare program  May have to use network doctors or hospitals 05/05/2011 Getting Started19

20  During 7 month initial enrollment period  Can join during annual fall open enrollment ◦ October 15 – December 7 each year ◦ Coverage begins January 1  May be able to join during other special times  Contact the plan to join ◦ Call their number ◦ Visit their website ◦ Plan information is available on 05/05/2011 20Getting Started

21  Still in Medicare with all rights and protections  Still get Part A and Part B services  Plan may include prescription drug coverage  May include extra benefits like vision or dental  Benefits and cost-sharing may be different 05/05/2011 Getting Started21

22  Consider ◦ Most offer comprehensive coverage  Including Part D drug coverage ◦ May require you to use a network ◦ You must pay monthly premium to plan  Still must pay Part B premium ◦ May need a referral to see a specialist ◦ Can only join/leave plan during certain periods ◦ Doesn’t work with Medigap policies ◦ Must have Part A and Part B to join 05/05/2011 22Getting Started

23  See Appendix C for costs ◦ In Original Medicare (Part A and Part B)  Make sure your doctor accepts “assignment” ◦ In Medicare Advantage  Check with plan ◦ In Medicare Prescription Drug Plans  Check with plan  Costs change yearly ◦ Updates are in Medicare & You handbook  Mailed every fall 05/05/2011 Getting Started23

24  Available for all people with Medicare  Provided through ◦ Medicare Prescription Drug Plans ◦ Medicare Advantage Plans ◦ Other Medicare plans  Must include range of drugs in each category 05/05/2011 Getting Started24

25  You must have Medicare Part A and/or Part B  You must live in the plan’s service area  You can’t live outside the U.S.  You can’t be incarcerated  You must enroll in a Medicare Part D plan ◦ In most cases no automatic enrollment ◦ You must fill out an application 05/05/2011 Getting Started25

26  Can join during 7 month initial enrollment period  Can join during annual fall open enrollment ◦ October 15 – December 7 ◦ Coverage starts January 1  Can join during other special times  Contact plan to join ◦ Call ◦ Visit website 05/05/2011 26Getting Started

27  Consider ◦ Do you have creditable drug coverage?  Coverage as good as Medicare’s  For example through an employer plan ◦ Will that coverage end when you retire? ◦ What is the cost of drugs you currently take? ◦ What is the cost of premiums for Part D plans? ◦ You may pay a penalty if you don’t take Part D when first eligible  Unless you have creditable coverage 05/05/2011 27Getting Started

28  Call or by computer ◦ 1-800-MEDICARE ◦ Plan Finder Tool at ◦ Call SHIP for help comparing plans  To join a Part D Plan ◦ Complete a paper application ◦ Call the plan ◦ Enroll on the plan’s Web site ◦ Enroll on ◦ Call 1-800-MEDICARE (1-800-633-4227) 05/05/2011 28Getting Started

29  Medicaid  Extra Help  Medicare Savings Programs 05/05/2011 29Getting Started

30  Federal-state health insurance program ◦ For people with limited income and resources ◦ Certain people with disabilities  Most costs covered for Medicare/Medicaid ◦ Called “dually eligible”  Eligibility determined by state  Application processes and benefits vary  State office names vary  Apply if you MIGHT qualify 05/05/2011 30Getting Started

31  Help paying prescription drug costs  Social Security or state makes determination  Some groups automatically qualify ◦ People with Medicare and Medicaid ◦ Supplemental Security Income (SSI) only ◦ Medicare Savings Programs  You or someone on your behalf can apply 05/05/2011 Getting Started31

32  Help from Medicaid paying Medicare costs ◦ Pay Medicare premiums ◦ May pay Medicare deductibles and coinsurance  Often higher income/resource guidelines  Income amounts change each year  Some states offer their own programs 05/05/2011 32Getting Started

33  Apply if you MIGHT qualify  Your SHIP can help you 05/05/2011 33Getting Started

34  Medicare is a health insurance program  It does not cover all health care costs for enrollees  There are other ways to get coverage within the program  Important ◦ Make the right decisions ◦ Make them at the right times ◦ Get help if you need it 05/05/2011 34Getting Started

35  Focus on Prevention, Improved Quality, Improved Access to Care, and Reducing Waste ◦ Elimination of Co-Insurance and Deductibles for most preventive tests ◦ Partnership for Patients, Center for Medicare and Medicaid Innovation ◦ New coverage options for the uninsured ◦ Increased criminal penalties for fraud, increased resources to combat it ◦ Effort to make Medicare Advantage (Part C) more cost effective and competitive 05/05/2011 Getting Started35

36  Why? ◦ 2,000 deaths/year from unnecessary surgery ◦ 7000 deaths/year from medication errors in hospitals  Medication errors are among the most common, harming at least 1.5 million people, costing $3.5 billion ◦ 20,000 deaths/year from other errors in hospitals ◦ 80,000 deaths/year from infections in hospitals ◦ 13% of Hospital Readmissions are avoidable  Cost $45 Billion/year

37  Early Retiree Reinsurance Program ◦ Provides financial relief for employers so retirees can get quality, affordable insurance  Pre-Existing Condition Plans Provide Access to coverage for those who cannot afford it ◦ A plan is in each state. Information can be found on ◦ The New York Plan is called the NY Bridge Plan. Its website is

38  ◦ Tool that can help the uninsured determine what coverage they may be eligible for ◦ Detailed Information on the Affordable Care Act

39 EPIC – New York’s Prescription Plan for Seniors  Supplements Part D 1-800-332-3742  HIICAP Program Provides Health Insurance Counseling to Medicare Beneficiaries 1-800-701-0501

40 General Medicare Questions and Complaints: 1-800-MEDICARE Coordination of Benefits Issues 1-800-999-1118 Community Health Advocates 888-614-5400

41  Medicare & You Handbook  National Medicare Training Program ◦ 05/05/2011 41Getting Started

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